Which of the following are complication associated with long term use of proton pump inhibitors?
A. Bone fractures
B. Hypomagnesemia
C. Vitamin B12 deficiency
D. Clostridium difficile infection
E. Helicobacter pylori infection
Correct Answer: D
Use proton pump inhibitors (PPIs) in patients with or who have risk factors for osteoporosis cautiously. PPIs have been associated with a possible increased risk of bone fractures of the hip, wrist, and spine. Daily treatment with a gastric acid- suppressing medication over a long period of time may lead to hypomagnesemia. Vitamin B12 deficiency has been reported with long term use of PPIs in the literatures. The use of PPIs, may increase the risk of enteric infection by encouraging the growth of gut microflora and increasing susceptibility to organism including Clostridium Difficile. There are recent FDA warnings regarding C. Diff infection with use of PPIs. H. Pylori infection is not a complication of PPIs. PPIs in combination with certain antibiotics are used to treat H. pylori Infections.
Question 42:
What indication usually requires higher dose of proton pump inhibitor?
A. Helicobacter pylori
B. Esophagitis
C. Duodenal ulcer
D. Stress ulcer prophylaxis
E. Zollinger-Ellison syndrome
Correct Answer: E
The diagnosis of Zollinger-Ellison syndrome is suggested when plasma gastrin is > 1000 pg/ml and the basal acid output is > 15 mEq/h or when associated with a pH andlt; 2. The treatment is focused on controlling gastric acid hypersecretion and localisation of the tumour and its metastases. Proton pump inhibitors are the most effective antisecretory drugs and can be administered at high dosages
Question 43:
Which of the following side effects should LT be made aware of while on Divalproex Sodium?
A. Weight gain
B. Oligomenorrhea
C. Alopecia
D. Gynecomastia
E. Gingival hyperplasia
Correct Answer: C
Common GI side effects of Valproic Acid and Divalproex Sodium are Weight gain, Nausea, Vomiting, Diarrhea, abdominal pain, dyspepsia. Divalproex sodium or valproic acid affects reproductive endocrine function in women. Menstrual irregularities defined as amenorrhea, oligomenorrhea, and prolonged cycles were common. Gynecomastia is not a side effect of Divalproex Sodium. For list of drugs that causes gynecomastia refer the reference. Gingival hyperplasia is a well- known side effect of phenytoin.
Which of the following Anti-epileptic medication can cause pancreatitis?
A. Carbamazepine
B. Gabapentin
C. Valproic acid
D. Levetiracetam
E. Phenobarbital
Correct Answer: C
Cases of life-threatening pancreatitis have been reported in both pediatric and adult patients receiving valproic acid or its analogs. Patients should be warned that abdominal pain, nausea, vomiting, and/or anorexia can be symptoms of pancreatitis that require prompt medical evaluation. If pancreatitis is diagnosed, valproate should be discontinued.
An order is received for 0.03 units /min of vasopressin for Sepsis to maintain MAP >65. The standard mixed in your hospital for vasopressin is 40 units in 100ml NS.
What is the rate in mLs/hr should the vasopressin be infused at?
A. 4.0 ml/hr
B. 4.9ml/hr
C. 4.5ml/hr
D. 3.5ml/hr
E. 6ml/hr
Correct Answer: C
Question 46:
Which of the following is recommended to be monitored in patients on Divalproex Sodium?
A. CBC
B. Serum ammonia
C. LFT's
D. Pulmonary function
E. Serum creatinine
Correct Answer: C
A, B, C. Hepatotoxicity, including hepatic failure, has been fatal and may more commonly occur in the first 6 months of treatment. Valproic acid and its analogs are contraindicated in patients with known urea cycle disorders. Patients with urea cycle disorders have a genetic enzyme defect leading to an impaired ability to produce urea. Hyperammonemic encephalopathy has been reported following initiation of valproate therapy. Because of, inhibition of the secondary phase of platelet aggregation, and abnormal coagulation parameters complete blood counts and coagulation tests are recommended before initiating valproic acid therapy and at periodic intervals.
Question 47:
After talking to the patient you find out LT has been incompliant with her three times a day Valproic acid, level came back at 35 mmol/L.
What is the most appropriate course of action?
A. Notify the physician to decrease the dose of Valproic acid.
B. Notify the physician to increse the dose of Valproic acid.
C. Albumin needs to be obtained to calculate corrected Valproic acid level
D. Valproic acid level is within normal limit, no adjustment is needed.
Correct Answer: D
The delayed-release action of divalproex allows for less frequent dosing than valproic acid in some patients. Divalproex sodium contains sodium valproate and valproic acid in a 1:1 molar stable coordination compound. Valproic acid, sodium valproate, and divalproex share the same pharmacology; however, there are pharmacokinetic differences among products.
Question 48:
After talking to the physician you find out her labs. Her labs reveled albumin level of 2.1gm/dL, calcium of 7.8mg/dL, glucose 120mg/dL , sodium 138 mmol/L, phenytoin level of 17.8.
Based on the given data which of the following best interprets phenytoin concentration?
A. Phenytoin level is with normal limits
B. Phenytoin level is too high
C. Phenytoin level is too low
D. Phenytoin level cannot be determined
E. Phenytoin level need to be repeated
Correct Answer: B
Corrected phenytoin (mg/L) = Observed phenytoin (mg/L) / (0.2 x albumin [g/dL]) + 0.1 = 17.8 / (0.2 x 2.1)
+ 0.1 = 17.8 / 0.42 + 0.1 = 42.48mg/L phenytoin level is high. Normal therapeutic range is: 10-20mg/dL
Question 49:
LT is a 42-year-old white female with past medical history of epilepsy, gastroesophageal reflux disease and seasonal allergies. She weighs 86 kg, height 5'6" and allergic to Aspirin (rash) and Phenobarbital (difficulty breathing).
Her medications include Omeprazole 40mg daily, Phenytoin 200mg twice daily, Valproic acid 500mg four times daily, Loratadine 10mg daily. She comes to your community pharmacy to pick up prescription for Primidone 250mg twice daily.
Pertaining to Primidone what is the most appropriate action to take?
A. Notify the physician, Primidone dose is too low.
B. Notify the physician, Primidone in contraindicated in patient with phenobarbital allergy.
C. Notify the physician, Primidone in contraindicated in patient with Aspirin allergy.
D. Notify the physician, patient is already on three anti-seizure medication and primidone is not needed.
E. Notify the physician, Primidone in contraindicated in patient with gastroesophageal reflux disease.
Correct Answer: B
Primidone is an anticonvulsant drug that is structurally related to phenobarbital. Primidone is metabolized to phenobarbital and therefore shares its anticonvulsant and sedative properties. Primidone may be more effective than therapy with phenobarbital alone because primidone and both of its metabolites, phenobarbital and phenylethylmalonamide (PEMA), possess anticonvulsant activity.
Question 50:
Select the class of Anti-diabetic medication that works in the specified organto prevent hyperglycemia. Select all that applies. Fat Tissue (H)
A. Sulfonylureas
B. Alpha- Glucosidase Inhibitors
C. DPP4 Inhibitors
D. Glucagon-like peptide-1 receptor agonists
E. Thiazolidinediones
F. Biguanide
G. SGLT2 inhibitors
Correct Answer: E
Thiazolidinediones Sulfonylureas work in beta cells in the pancreas that are still functioning to enhance insulin secretion. Alpha-Glucosidase Inhibitors stop -glucosidase enzymes in the small intestine and delay digestion and absorption of starch and disaccharides which lowers the levels of glucose after meals. DPP4 blocks the degradation ofGLP-1, GIP, and a variety of other peptides, including brain natriuretic peptide. Glucagon-like peptide-1 receptor agonists work in various organs of the body. Glucagon-like peptide-1 receptor agonists enhance glucose homeostasis through: (i) stimulation of insulin secretion; (ii) inhibition of glucagon secretion; (iii) direct and indirect suppression of endogenous glucose production; (iv) suppression of appetite; (v) enhanced insulin sensitivity secondary to weight loss; (vi) delayed gastric emptying, resulting in decreased postprandial hyperglycaemia. Thiazolidinediones are the only true insulinsensitising agents, exerting their effects in skeletal and cardiac muscle, liver, and adipose tissue. It ameliorates insulin resistance, decreases visceral fat. Biguanides work in liver, muscle, adipose tissue via activation of AMP-activated protein kinase (AMPK) reduce hepatic glucose production. SGLT2 inhibitors work in the kidneys to inhibit sodium-glucose transport proteins to reabsorb glucose into the blood from muscle cells; overall this helps to improve insulin release from the beta cells of the pancreas.
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